Course Registration Form

Registration Form

Fill out the form carefully for registration
Applicant Name*

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
Gender*
Gender*
Social Security Number*
###-##-####
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Date*

MonthDayYear
Date
E-mail*
example@example.com
Citizenship
Place of Birth *
City/Town, State/Providence, and Contry
Type of Citizenship*

US CitizenDual CitizenUS Permanent Resident VisaOther Citizenship
If anything other than US Citizen checked above please state your citizenship of which country, alien registration number, and/or visa below.
Ethnicity

Race/Ethnicity information is optional. Information you provide will not be used in a discriminatory manner.
Are you Hispanic or Latino?

YesNo
How would you describe your racial background?

AsianAfrican American/BlackAmerican Indian/Alaska NativeNative Hawaiin/Pacific IslanderWhite/CaucasianMiddle Eastern
Academic Information
Name of High School*
Location of High School*

School Address

Street Address Line 1

CityState / Province

Postal / Zip Code
Start Date of High School*
Date of Graduation *
School Phone
School Fax
Are you currently enrolled in school?*

YesNo
Did you receive a GED?*

YesNo
If so, list date below:
If your education had been interrupted, please detail your activities since last enrolled.
Employment History

(Please add at least 10 years of employment history)
Employer 1*
Name: City: State: Start Date: End Date: Job Title: Job Description: Responsibilities & Duties:Please include the Name, City, State, Start & End Date, Job Title, and Job Description
Employer 2*
Name: City: State: Start Date: End Date: Job Title: Job Description: Responsibilities & Duties:Please include the Name, City, State, Start & End Date, Job Title, and Job Description
Employer 3*
Name: City: State: Start Date: End Date: Job Title: Job Description: Responsibilities & Duties:Please include the Name, City, State, Start & End Date, Job Title, and Job Description
Employer 4*
Name: City: State: Start Date: End Date: Job Title: Job Description: Responsibilities & Duties:Please include the Name, City, State, Start & End Date, Job Title, and Job Description
Employer 5*
Name: City: State: Start Date: End Date: Job Title: Job Description: Responsibilities & Duties:Please include the Name, City, State, Start & End Date, Job Title, and Job Description
What would describe your trade as?*

BoilermakerCarpenter/Scaffold BuilderCombo WelderPipefitterPainterMechanicOther
Personal Statement *
Please add a personal statement to highlight your professional skills
Union
Have you ever been apart of the union?*

YesNo
If answered yes to the above question please input your: Local Union, Local Number, City State. If answered “No” please type N/A*
Selective Service
Are you Active Military/Veteran (required)?*

YesNo
If Active or Retired Military which Branch or service?

ArmyNavyMarinesAir Force
Discipline Information
Have you ever been placed on probation, suspended, removed, dismissed or expelled from any school or academic program since 9th grade?*

YesNo
Other than traffic offenses, have you ever convicted of any misdemeanor or felony?*

YesNo
If you answered yes to either question, please provide an explanation and the approximate dates of each incident
Authorization

By selecting the submit button below it authorizes that all schools you attended and jobs performed , can provide all requested records and allows review of your application for the admission process chosen on this application. It also confirms all information in this application (including any supplemental information) is factually true and honestly presented and that you are the person submitting this application.
Signature*

Clear
By signing this document, you are giving your express written consent for The LMC Groupe to contact you regarding our educational programs and services using email, telephone or text – including our use of automated technology for calls or texts to any wireless number you provide. This consent is not required to purchase goods or services. The LMC Groupe does not discriminate on the basis of race, color, religion (creed), gender, gender expression, age, national origin (ancestry), disability, marital status, sexual orientation, or military status, in any of its activities or operations.
Should be Empty:

Registration Form

Citizenship

Ethnicity

Academic Information

Employment History

Union

Selective Service

Discipline Information

Authorization